The nurse is assessing a client for pain. Which of the following statements is most likely to result in the most meaningful assessment data about pain?
a. Where does the pain usually occur?
b. Is the pain sharp or dull?
c. What were you doing when the pain began?
d. Describe the pain in your own words.
ANS: D
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A nurse is caring for a client in Buck's skin traction. Which of the following indicates a need for corrective action?
A) The traction weights are touching the floor. B) The traction is being applied continuously. C) The countertraction is opposite to the pull of traction. D) The client's mobility is limited.
The nurse is planning care for the client with an aneurysm. A priority of care for this client is:
1. Carefully trimming finger- and toenails. 2. Limiting visitors. 3. Protecting from infection. 4. Addressing anxiety.
A 52-year-old woman admitted to the same-day surgical unit for wire needle localization and biopsy states, "My surgeon explained the need for putting a wire in my breast, but I don't remember exactly why I need to have it."
What is the nurse's best response? A) "I have not seen it done before but I understand that it is for aspirating the fluid." B) "The wire is used to locate the mass using an x-ray and it will establish the location." C) "You will have a core biopsy with the use of the MRI to find the mass." D) "You will have a portion of the mass removed and then the surgeon will decide the treatment."
The nurse would determine that which of the following clients has the greatest risk of developing heart failure?
1. A 50-year-old African American female who smokes 2. A 69-year-old African American male with hypertension 3. A 75-year-old Caucasian male who is overweight 4. A 52-year-old Caucasian female with asthma